translation: mentalizing as treatment target in...

Translation: Mentalization as Treatment Target in BPD 1

This is the accepted version of a paper for publication in Personality Disorders: Theory, Research, and

Treatment (http://www.apa.org/pubs/journals/per/index.aspx). This article may not exactly replicate the final

version published in the APA journal. It is not the copy of record. © American Psychological Association.

December 30, 2014.

Translation: Mentalizing as treatment target in Borderline Personality Disorder

Peter Fonagy

Research Department of Clinical, Educational and Health Psychology, University College

London, UK

Patrick Luyten

Faculty of Psychology and Educational Sciences, University of Leuven, Belgium


London, UK

Anthony Bateman

Halliwick Personality Disorder Service, St Ann’s Hospital, London

Correspondence concerning this chapter should be addressed to Peter Fonagy,


London, Gower Street, London WC1E 6BT, UK. E-mail: [email protected]





December 30, 2014.

Translation: Mentalizing as Treatment Target in Borderline Personality Disorder

This paper focuses on the clinical application of mentalizing ideas to the treatment of

BPD. Over the past decades a number of evidence based treatment approaches for this severe

condition have been developed, MBT being one of these (Stoffers et al., 2012). Here we

examine the role of mentalizing in relation to BPD with a view to achieving improved levels

of mentalizing in BPD patients as a therapeutic target. We seek to explain why mentalizing

works as a treatment target for BPD, and argue that a mentalizing approach to BPD is at the

core of any successful intervention. Recent developments in our understanding of mentalizing

continue to influence approaches to treatment and this paper presents an update of the general

theoretical and clinical approach, and specific treatment interventions and principles.

Mentalizing is the ability to understand others in terms of their thoughts, feelings,

wishes, and desires; it is a very human capability that underpins everyday interactions.

Without mentalizing there can be no robust sense of self, no constructive social interaction,

no mutuality in relationships and no sense of personal security (Fonagy, Gergely, Jurist, &

Target, 2002). Mentalizing is therefore a fundamental psychological process and so interfaces

with all major mental disorders and has generic applicability in psychiatric care (Allen,

Bleiberg, & Haslam-Hopwood, 2003; Choi-Kain & Gunderson, 2008).

Although mentalizing techniques are now applied to a wide range of psychological

disorders (Bateman & Fonagy, 2012), it is for borderline personality disorder (BPD) that

mentalization based treatment (MBT) was first developed and for which it has the most

substantial evidence base (Bateman & Fonagy, 2003; Bateman & Fonagy, 2004; Bateman &

Tyrer, 2004). The first section of this paper is an introduction to mentalizing in the context of

BPD: it gives an overview of the development of the components that comprise full

mentalization and how these are typically manifest in BPD patients, with a view to





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appreciating how this contributes to our understanding of treatment targets for BPD. The

second section explores the theory of social learning and epistemic trust in order to explore

systems for therapeutic change in BPD and how this links to the importance of mentalizing as

a theoretically cross-cutting factor across any successful therapeutic intervention. The third

section focuses on translation of theory into practice in the consulting room: it goes into

further detail about how therapy can and should address the typical mentalizing features and

profiles of BPD patients overviewed in the first section, and factors contributing to the failure

to develop full mentalizing as explored in the second section. The implications of the content

covered in the previous sections are discussed in terms of the principles, structure, protocols

and technique of MBT, and illustrated with clinical examples.

Attachment, mentalizing, and BPD

There has been much fruitful discussion of the role of mentalizing in the origins of

BPD and the ways in which infants and children learn about managing relationships and

emotional states (e.g. Fonagy & Bateman, 2008). Mentalizing skills are acquired in the

context of early attachment relationships, which have typically been found to be preoccupied

and disorganized in BPD patients (Choi-Kain, Fitzmaurice, Zanarini, Laverdiere, &

Gunderson, 2009; Levy, Beeney, & Temes, 2011). Yet, attachment problems alone cannot

explain the typical clinical picture of BPD. Problems in affect regulation, attentional control,

and self-control stemming from dysfunctional attachment relationships (Aaronson, Bender,

Skodol, & Gunderson, 2006; Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004; Barone,

Fossati, & Guiducci, 2011; Lyons-Ruth, Yellin, Melnick, & Atwood, 2005; Scott et al., 2013;

Sroufe, Egeland, Carlson, & Collins, 2005) are thought to be mediated through a failure to

develop a robust mentalizing capacity (Fonagy & Bateman, 2008). In line with these

assumptions, we see the defining characteristics of BPD – emotional dysregulation,

impulsivity, interpersonal dysfunction – as rooted in an instability of the reflective, regulatory





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capacities that mentalizing affords. From a wider mentalizing perspective, mental disorders in

general can be seen as the mind misinterpreting its own experience of itself and of others

(Bateman & Fonagy, 2010).

The potential for mentalizing seems to be an innate human characteristic (Kovacs,

Teglas, & Endress, 2010) but the full acquisition of this ability is a developmental

achievement, one that is likely to be highly responsive to environmental influences (Fonagy,

Target, Gergely, Allen, & Bateman, 2003). Mentalizing capacities seem dependent on the

quality of the early social learning environment and early attachment experiences;

specifically, the attachment figures’ ability to respond with contingent and marked affective

displays in response to the infant’s subjective experience. Mentalizing is thus seen as a

fundamentally bi-directional or transactional social process (Fonagy & Target, 1997): it is

influenced by the capacity of our attachment figures to mentalize, but their capacity to

mentalize is also influenced by the child’s characteristics (e.g., temperament), reflecting so-

called evocative person-environment interactions (Fonagy, 2003; P. Fonagy, Luyten, &

Strathearn, 2011).

The bi-directional nature of mentalizing is clearly fundamental to understanding its

developmental origins, and has considerable bearing on how we conceptualize mental

disorders in relation to their characteristic interpersonal difficulties. It is also central to how

we formulate the treatment and treatment targets for psychotherapy in BPD. For individuals

who have not benefitted from a stable and secure early environment in which they

experienced consistent validation of their thoughts and feelings (Linehan, 1993), an effective

therapeutic environment will be a theater for an introduction to mentalizing skills. The

objective of reaching a state of improved mentalizing in the patient is reached through an

interactional process whereby the therapist models their own mentalizing capacities and

demonstrates their ability to mentalize the patient. In other words, mentalizing as an end





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target is achieved through the experience of being effectively mentalized; it is an implicitly

processed experience as well as a target of treatment.

The Multiple Mentalizing Competencies

We have conceptualized mentalizing as comprised of four attributes or polarities, each

with two opposing values, or poles (Luyten & Fonagy, this issue). We assume that the

limitations in mentalizing shown by BPD patients are explained by lack of balance across

these polarities (see Figure 1). The aim of MBT is to address this imbalance in a manner that

is closely attentive to moment-to-moment changes in current functioning. Consideration of

the polarities of mentalizing is helpful in locating the loci where therapists should work (and

probably normally find themselves working whether they are doing MBT or not) to restore an

equilibrium into mentalizing capacity. Here, we consider how a BPD patient typically

presents in relation to each polarity, and the resulting implications for therapy.

The automatic-controlled polarity: Controlled mentalizing is conscious, verbal, and

reflective; automatic mentalizing is nonconscious, nonverbal, and unreflective. Individuals

with BPD often tend toward this latter form of mentalizing. BPD patients are particularly

likely to fall back on automatic mentalizing at moments of intense emotional arousal (e.g., in

attachment contexts, challenging interpersonal situations, feelings of shame, guilt, anger, or

inadequacy), often with severe impairments in social cognition as a consequence (e.g., being

overly distrustful or trustful, being idealizing or overly denigrating).

The dramatically reduced capacity of BPD patients for reflective functioning (Fonagy

et al. (1996)) that is necessary for controlled mentalizing has been shown to be reversible by

psychotherapy (Levy et al., 2006). The task of the therapist, then, is to help slow down the

patient’s thinking and move them to a more reflective, explicit form of mentalizing which

requires more conscious, verbal attention; all without generating a process of pseudo

reflection or hypermentalizing (Sharp et al., 2013; Sharp et al., 2011).





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The external–internal polarity: BPD patients tend to interpret the mental states of

others on the basis of exterior cues (physical and visible features such as gestures or actions,

or even their own actions) at the expense of internal ones. Indeed, the heightened sensitivity

to emotional experiences in BPD seems to be intrinsically related to an increased sensitivity

to external features of self and others as a source of knowledge about mental states (Fonagy

& Luyten, in press).

The hypersensitivity of BPD patients to others’ emotions (Gunderson & Lyons-Ruth,

2008), including those of the therapist, means that they often fail to develop plausible

scenarios concerning others’ states of mind based on these feelings, and are unable or

unwilling to consider alternative explanations. Interventions that target mentalizing often

need to start by examining interpretations based on external features and then generate

possible plausible scenarios about internal states of mind, particularly the subtleties and

complexities of people’s internal worlds. The task of the therapist is to attempt to move the

patient’s focus to mental interiors: the thoughts, feelings, history and experiences that might

offer further insight into someone’s behavior. This shift involves not only slowing patients

down and encouraging them to recognize their assumptions (e.g. relying on controlled or

explicit mentalizing), but also to start to consider other people’s subjective experiences using

inference alongside mental state judgments based on appearance.

The affective-cognitive polarity: Full mentalizing involves the integration of

cognitive belief-states (dominated by a cognitive awareness of how other people’s attitudes

and behavior are shaped by their own mental states and beliefs) and affective knowledge

(dominated by inferences drawn from one’s own feelings, self-affective state propositions).

BPD patients often over-rely on the logic of emotion in preference to the logic of cognition

when assessing subjective states, and indiscriminatingly apply the very particular logic of

emotion to wider thoughts and beliefs (Fonagy & Luyten, 2009). These individuals thus will





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show a bias toward attributing their own self-states to others (Baron-Cohen, Golan,

Chakrabarti, & Belmonte, 2008; Baron-Cohen, Tager-Flusberg, & Cohen, 2000). At

extremes, mental reality and physical/outer reality become equated and the patient’s genuine

sense of conviction generates a so-called “concrete understanding” of psychological

experience and an intolerance of alternative perspectives.

The therapeutic target would be to encourage the patient to step back from this

collapsing of appearance and reality, drawing attention to the patient’s vulnerability to

emotional contagion and their difficulty in inserting doubt or uncertainty into a process of

inference. The BPD patient will frequently experience moments in which they are

overwhelmed by affect; the response of the therapist should be to help the patient integrate

this intense sense of affective knowledge or awareness (whether about the self or others) with

more reflective and cognitive knowledge.

The self–other polarity: The capacity to differentiate between the self and other is

often severely impaired in BPD patients (e.g., Barnow, Ruge, Spitzer, & Freyberger, 2005;

Bender & Skodol, 2007; Blatt & Auerbach, 1988; Fuchs, 2007; Kernberg, 1984). From a

mentalizing perspective, proneness to self-other confusion is explained by these patients’

frequent inability to inhibit their own reactions when they are thinking about the mind of

someone else. This means that the shared world and individual minds are not clearly

demarcated for them; they fully expect others to know what they are thinking and feeling and

to see situations in the same way they do. This may also explain the common experience of

therapists who find that BPD patients are determined to control the thoughts and feelings of

those around them. Underpinning their apparent need for control may be an inability to

inhibit the impingement of others’ mental states (Rigoni, Brass, Roger, Vidal, & Sartori,

2013; Spengler, von Cramon, & Brass, 2010).





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When a patient starts to talk about their own state in a non-mentalizing

(hypermentalizing or overly concrete) way, the strategy adopted in MBT is to shift the

patient’s attention to the mental state of others. This “contrary move”, one of the typical

interventions in MBT, aims to surprise the patient and force him/her to mentalize the states of

others. Similarly, when the patient becomes intensely concerned with someone else’s mental

state, it may be helpful for them to consider how this preoccupation is affecting their own

functioning. Working to shift the patient’s thoughts and feelings between the self and the

other in a consistent, flexibly responsive way targets the patient’s tendency to become rigidly

stuck in an unproductive mode of mentalizing by enabling him/her to be cognizant of the

differences between himself/herself and others.

In working across the four mentalizing polarities, the basic and consistent aim is to re-

establish mentalizing when it is lost – the typical starting point of mentalization-based

interventions. This is clearest when a balanced form of mentalizing is no longer obvious. The

task is not to seek structural or personality change in the patient with BPD, or explicitly aim

to alter their representations, cognitions or schemas. Rather, the emphasis is on improving the

patient’s capacity for mentalizing and to make their mentalizing skills more stable and robust

so that they are more able to manage affect and think about problems, particularly within

interpersonal relationships.

Prementalizing Modes

Modes of prementalizing tend to re-emerge whenever we lose the ability to mentalize,

as typically happens in individuals with BPD, particularly in high arousal contexts (Fonagy &

Target, 1997). We now understand the emergence of these non-mentalizing modes as

indications of imbalance in mentalizing, where it comes to be dominated by one end of a

mentalizing polarity, presumably as a function of weakening of the other pole.

Conceptualizing this in terms of characteristic modes of subjectivity provides a further way





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of appreciating the phenomenology of individuals with BPD features and thus provides the

basis for a helpful formulation for clinical work.

In the psychic equivalence mode, thoughts and feelings become “too real”, and there

are no conceivable alternative perspectives. In children under five years old, this inability to

separate thought from reality is omnipresent (Gopnik, 1993). There is a suspension of doubt;

the individual increasingly believes that their own perspective is the only one possible. As we

have seen, this state reflects the domination of the propositional logic of emotion states

(where reality is defined by self-experience) over the propositional logic of cognition (where

agent:attitude propositions permit knowledge that belief is independent of reality; Baron-

Cohen et al., 2008). Psychic equivalence makes all subjective experience excessively real.

The overwhelming mental pain reported by BPD patients (Zanarini & Frankenburg, 2007) is,

in our view, rooted in this aspect of mentalizing dysfunction.

In the teleological mode, there is only recognition of real, observable goal-directed

behavior and objectively discernible events. The individual can recognize the existence and

potential role of mental states, but this recognition is limited to very concrete, observable

goals. Congruent with this position, the individual cannot accept anything other than a

modification in the realm of the physical as a true index of the intentions of the other. This

reflects an extreme exterior focus in the mentalizing profile. The action proneness of

individuals with BPD is often, rightly or wrongly, considered under the heading of

impulsivity (Lawrence, Allen, & Chanen, 2010; Sebastian, Jacob, Lieb, & Tuscher, 2013).

From a mentalizing perspective, impulsivity is associated with the externally focused

subjectivity of the individual with BPD. If physical and visible features are prioritized,

others’ or one’s own actions also become an inevitable focus. If a focus on “mental interiors

– on thoughts, feelings and experiences – is inaccessible, then subjective reality may be

possible to create only by making an impact on the physical world, whether that outer reality





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is that of the social world (creating an impact through getting others to act) or the more

constrained world of one’s own body (Lemma, 2012).

In pretend mode, thoughts and feelings become severed from reality (which we term

“hypermentalizing” or “pseudomentalizing”). Again, a mode of pretending, where reality is

suspended and internal states are all that matter, is universal in young children, yet such states

of mind are readily punctured when reality (or an adult) intrudes into the game. Retreating to

this mode in adulthood is associated with a sense of meaninglessness which may be defensive

but is no longer experienced as pleasurable. It is linked to an experience of emptiness, which

may result in the individual becoming dependent on strong guiding voices that seem to

promise a sense of meaning. These features of BPD are neglected in research and theoretical

conceptualizations of this condition – quite inappropriately, in our opinion, given their

prevalence and significance (Luyten, Fonagy, Lowyck, & Vermote, 2012; Sharp et al., 2011).

In these states, ideas form no bridge between inner and outer reality; the mental world is no

longer fully coupled with external reality. To make things feel real, a person in desperation

may turn to self-injury or other dramatic acts to break out of the feeling of emptiness. The

subjective experience of meaninglessness is a manifestation of what happens when explicit

mentalizing is overridden by implicit mentalizing, so that there is excessive internal focus

unchecked by reflection. A common consequence is hypermentalizing, where groundless

inferences are made about mental states, sometimes reminiscent of confabulation. The

ultimate meaninglessness of hypermentalizing is assured by other failures in the mentalizing

process including poor belief-desire reasoning, a vulnerability to fusion with others’ identity,

and a tendency to become lost in the complexity of the world of beliefs and desires with

which physical reality is only loosely coupled.

These three prementalizing modes are particularly important as they are often

accompanied by a more acute experience of disorganization within the experience of the self.





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Most modern psychology assumes that self-coherence (the sense that one has continuity and

consistency in thought and behavior) is somewhat an illusion (Bargh, 2011, 2014). It is an

illusion that is maintained by the creation of a mentalizing narrative around one’s thoughts

and feelings, which in turn helps to create a coherent self-structure. If weakness of

mentalizing capacity undermines this integrative process, incoherence in self-representation

is likely to arise. Torturous feelings of badness, possibly linked to experiences of abuse which

are felt to be part of the self but are not integrated with it (so-called “alien-self” parts), come

to dominate self-experience. We assume that these discontinuities in self-experience (when

the person feels aspects of their self-experience to be of themselves or their own, and yet also

alien to their self-experience) generate a sense of incongruence, which is dealt with through

externalizing – behaving toward others as though the others own the unmentalized self-

experiences and on occasions even being successful in generating these experiences in them

(Fonagy & Target, 2000). This brings about relief, even if the immediate impact of

externalizing a torturing part of the self in this way is to manipulate another person into

punitive persecutory behavior towards oneself. Because of their intensity, the person with

BPD experiences no option but to rid themselves of these feelings and attempt to dominate

the mind of others by “manipulativeness”, self-injury, or other types of behavior that in the

teleological mode are expected to relieve tension and arousal (Fonagy & Target, 2000).

Mentalizing Profiles: Complexities and Paradoxes

Understanding the different components and spectrums of mentalizing, as well as

propensities towards certain modes of prementalization, is central to understanding

mentalizing in BPD patients and how it should be targeted therapeutically (Fonagy & Luyten,

2009). Improved mentalizing can only genuinely be reached by appreciating the particular

strengths and weaknesses in mentalizing that any patient may show, and how these abilities

may be undermined or reinforced in different situations.





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The therapist should recognize that an individual’s capacity to mentalize varies across

time according to their environment and stress arousal level. In particular, gaps in

mentalizing in BPD patients are more likely to occur when the attachment system has been

triggered (Chiesa & Fonagy, 2014; Fonagy et al., 1996). This inextricable link between

mentalizing and attachment arousal means that mentalizing impairments in BPD may be

partly relationship-specific. Assessment and evaluation of mentalization of BPD patients is

therefore potentially unhelpful without regard to context. Any anomalies in relation to

mentalizing are unlikely to be manifest in BPD patients unless the relationship in which

mentalizing is being observed “pulls” for controlled mentalizing. The higher the level of

attachment arousal in a particular relationship at a particular moment, the more likely that

anomalies in mentalizing will emerge in these patients. Evidence strongly implies that as the

attachment bond between therapist and client intensifies, the quality of BPD patients’

mentalizing will tend to deteriorate (Diamond, Stovall-McClough, Clarkin, & Levy, 2003).

Thus, initial assessment of clients can leave therapists with the impression that they are

working with an individual with relatively high psychological mindedness (Bateman &

Fonagy, 2012) and someone highly suitable for insight oriented psychotherapy. As trauma is

typically associated with attachment insecurity, and anxious and disorganized attachment in

particular, more traditional insight-oriented treatments might be especially risky (Fonagy &

Bateman, 2006). Furthermore, transference typically intensifies as treatment progresses,

activating the patient’s internal working models of particular child–parent relationships and

their attachment system in general; the quality of psychological mindedness is likely to

deteriorate significantly and the patient’s capacity to perceive the therapist’s mind as different

from his or her own mental state will be quite limited at times (Allen, Fonagy, & Bateman,

2008). Treatment should therefore aim to find the optimal balance between attachment





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activation and mentalizing (Fonagy & Bateman, 2006) as well as applying an especially

sensitive approach to mentalizing in the context of remembering trauma (Allen, 2012, 2013).

With regards to the multi-dimensional nature of mentalizing, it has long been

observed that BPD patients are not necessarily unable to mentalize; they may in some

respects and in certain situations show normal or even superior mentalizing skills. Individuals

with BPD commonly excel in one particular form of mentalizing: intuitive empathy. This

contrast between eminent capability in intuitive empathy and drastic impairment in other

areas of mentalizing is commonly referred to as the “empathy paradox”. Dinsdale and Crespi

(2013) reviewed 28 studies of empathic functioning in BPD in an attempt to resolve the so-

called “empathy paradox”. They report that in about half the studies, mentalizing – assessed

in terms of levels of empathy – is enhanced in BPD. They particularly note the superiority of

BPD patients in tasks that call for inference of others’ intentions (as in Ladisich & Feil,

1988), or perceiving and responding strategically to small social cues indicating fairness

(Franzen et al., 2011). Some studies have found that individuals with BPD are superior to

normal controls in the accuracy with which they attribute mental states to others on the basis

of external features (e.g., Domes et al., 2008; Lynch et al., 2006; Schulze, Domes, Koppen, &

Herpertz, 2013); (yet see Matzke, Herpertz, Berger, Fleischer, & Domes, 2014; Mier et al.,

2013), indicating the reliance of BPD patient on the use of external cues in their assessment

of mental states. Furthermore, Ladisich and Feil (1988) assessed the perception of other

people’s feelings and personality by comparing individuals’ self-ratings with personality

ratings made by others (BPD patients, non-BPD patients, and psychiatrist expert raters).

Ratings made by BPD patients matched self-ratings better than those of non-BPD patients,

indicating higher empathy among the BPD patients, although they did not quite manage to

outperform the expert raters. The experience of “borderline empathy” is familiar to most

therapists suddenly struck by a remarkably insightful comment by their BPD patient.





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However, the superior intuition often displayed by individuals with BPD will often be

conspicuously absent in times of interpersonal stress and activation of the attachment system.

The dangers of not recognizing the unevenness and complexity of an individual’s

mentalizing performance can lead to the apparently iatrogenic effects often described in

unsuccessful therapeutic encounters for BPD (Higgitt & Fonagy, 1992). Therapists working

with BPD patients usually learn to recognize that exceptional interpersonal sensitivity should

not be taken as an indication of psychological mindedness (Bateman & Fonagy, 2006).

However, some therapists may misjudge this and address issues at a level of complexity

which is simply beyond the patient’s capacity to process (Fonagy & Bateman, 2006). Such

unwarranted sophistication will result in failure to overcome the rigidity of thinking that

characterizes patients with personality disorders in general. In the next section we will

discuss the theory of epistemic trust and how this might account for the rigid, ‘hard-to-reach’

quality observed in individuals with BPD.

Mentalizing and Communication: A Common Factor in the Treatment of BPD?

We argue that the reasons for the importance of using mentalizing as a target for

therapy in BPD partly lie in the particular attachment history and impairments in mentalizing,

and related epistemic hypervigilance (Fonagy, Luyten, & Allison, 2014), of patients with

BPD. The special significance of emotional neglect and abuse to BPD is particularly

accounted for by the theory of epistemic trust (Sperber et al., 2010). Sperber suggests that

evolution has prepared us to acquire culturally relevant new knowledge either because of its

content (e.g., its deductive relations with other beliefs which we arrive at though logical

inference) or, more commonly, we accept knowledge about our world and about ourselves

from “teachers” on account of their authority as a source of knowledge, which overcomes

natural and appropriate epistemic vigilance (Sperber et al., 2010). Such information may be

considered to be “deferentially” transmitted, (Recanati, 1997) by someone whose





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communication has the quality of epistemic trust: its source is known, remembered and

judged to be reliable (or epistemically trustworthy). This information can then be assumed to

be common knowledge shared by members of one’s community.

But what of an individual whose social experiences have led them to a state of chronic

epistemic mistrust, where (perhaps because of hypermentalizing) they imagine the motives of

the communicator to be malign? In this context the individual will appear to be resistant to

new information, might be considered to be rigid or even bloody-minded, because they treat

new knowledge from the communicator with deep suspicion and will not internalize it (i.e.,

modify internal structures to accommodate it). Their epistemic trust has been undermined,

and an evolutionarily prepared channel for the acquisition of personally relevant information

is blocked. We suspect that it is less likely to be the frank brutality of abuse that undermines

epistemic trust (although of course it can do) and that neglect and emotional abuse will play a

larger role in making an individual excessively vulnerable to disturbances in trusting

information from others. Taking the perspective of epistemic trust as the mediator of culture,

and its key underlying engine for progression, we now consider the destruction of trust in

social knowledge as the key mechanism in pathological personality development.

It is the disturbance of epistemic trust in our opinion that generates the apparent

rigidity typical of BPD patients. The rigidity, however, is in the eyes of the communicator

who, in accordance with the principles of theoretical rationality, expects the recipient to

modify their behavior on the basis of the information they received and apparently

understood. But, in the absence of trust, the capacity for change is absent. The information

presented is not used to update the individual’s social understanding. In terms of the theory of

natural pedagogy (Csibra & Gergely, 2009), the person has (temporarily) lost the capacity for

social learning. From a therapist’s standpoint, he/she has become hard to reach and

interpersonally inaccessible. Research suggests that there may be different routes to





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problems with epistemic distrust in BPD (Fonagy & Luyten, in press). In most patients,

problems trusting others as a source of knowledge about the world reflect a combination of

cognitive problems, impulsivity, and disruptions in attachment relationships, and trauma in

particular. The typical affect-driven, automatic mentalizing of BPD patients further disrupts

epistemic trust.

The Learning Systems Involved in Improved Mentalizing

It is an empirical fact that a number of psychotherapies appear to work roughly

equally well in the treatment of BPD. Based on the mentalizing model of BPD and the model

of communication outlined above, we argue that three systems underpin the process of

therapeutic change in BPD. In our opinion, these three systems relate to each other in order,

cumulatively, to make change possible. Yet, current views tend to favor and prioritize

primarily the first of these systems, leading to a relative neglect of the two other systems.

Communication System 1: The teaching and learning of content

All evidence-based treatments of BPD provide a coherent, consistent, and continuous

framework enabling the patient to examine, in a safe and low-arousal context, the issues that

are deemed central according to the theoretical approach concerned (e.g., early schemas,

invalidating experiences, object relations, attachment experiences). Across the course of

therapeutic treatment – if the treatment is sufficiently coherent, reliable and predictable in its

delivery – the patient begins to feel safe enough to allow a relaxation of epistemic

hypervigilance. This enables the patient to reach a point where they can digest and

contemplate the therapeutic “wisdom” being proposed to them. The relative importance of

System 1 needs to be understood: therapies without a coherent body of knowledge based on

systematically established principles have been observed to fail – to that extent, the content of

this “wisdom” matters (Fonagy & Bateman, 2006). All evidence-based effective models of





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therapy present the patient with models of mind, disorder, and processes of change that are

convincing and accurate enough to let the patient relax their hypervigilance and see the

model’s relevance to their state of mind. This process of teaching and learning between

therapist and patient – of showing the relevance of the wisdom (or the theory that underpins

the orientation) – is made possible only by mentalizing and a collaborative working approach

that models a mentalizing stance. However, the fact that there are so many different therapies,

using so many different theoretical models that have been found to have some beneficial

effect, indicates that the significance of System 1 lies not so much in the essential truth of its

wisdom as in the fact that it allows the patient to put to apply this new learning in a more or

less concrete way. This brings us to System 2.

Communication System 2: The re-emergence of social learning

Where System 1 concerns the content of what is learned in treatment, System 2 is

concerned with how learning is made possible again. In the process of effectively passing on

knowledge about the patient’s condition (in System 1), the therapist uses ostensive cues

(Russell, 1940; Wilson & Sperber, 2012), which signal meaningful communication of

relevance. As Csibra and Gergely (2011) have established, this signaling works through

conveying that the communicator is specifically and uniquely concerned with the individual

being communicated to and is seeking to understand that individual’s perspective. Ostensive

communication with the patient is in essence modeling mentalizing. By creating an open and

trustworthy social situation, a better understanding of the other is made possible. This in turn

allows for a more trusting, less paranoid interpersonal relationship between therapist and

patient, which facilitates not just the transmission of model-specific knowledge (as in System

1) but, through improving the patient’s capacity to understand others, regenerates their

potential to receive and absorb social information again. Ideally, the patient’s feeling of

having been sensitively responded to opens a virtuous cycle in interpersonal communications





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in which mentalizing has been learned to be possible; this, in turn, facilitates learning from

others about one’s own mind as well as about the mind of others. By the therapist showing

that their mind has been changed by the patient, they are giving agency to the patient and

increasing their faith in the value of social understanding.

Communication System 3: Learning beyond therapy.

The erosion of epistemic hypervigilance and the improvements in mentalizing that the

patient experiences in the context of the therapeutic relationship is likely to lead to

meaningful change only if the virtuous circle of communication is maintained beyond

therapy. Improvements in mentalizing lead to improvements in social relations, and a higher

level of epistemic trust enables the individual to learn from their social experiences in a

positive way. This goes beyond applying insights gained in treatment to relationships outside

treatment, as the generalization of knowledge belongs to System 1 (and in part also to System

2). Learning beyond therapy involves much more, and is also not that easy. The advantages

of these engagements with the wider social world are available to the patient only if their

social environment is benign enough to generate such benefits.

The common feature in successful therapies, despite their often wildly different

approaches, is thus, in our opinion, that they involve mentalizing. Mentalizing is a generic

way of establishing epistemic trust, and therefore achieving change by being open to different

kinds of social experience. Having one’s subjectivity understood – that is, being mentalized

by someone else – is the necessary key to reopening the ability to learn about and from the

social world. The experience of being safely and appropriately thought about then makes the

patient feel safe enough to go on to think about the wider social world. Mentalizing opens up

communication – the epistemic superhighway for the transfer of personally relevant

information, the fundamental biological route to information transmission – and, therefore,

the possibility of changing perceptions, expectations and information about others, about





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social processes, and the myriad knowledge elements that sustain all of us and support our

adaptation to the social world.

Implications for Treatment

The Mentalizing Focus in Mentalization-Based Treatment

While we have already discussed general treatment principles following from our

considerations concerning the nature and origins of BPD, the mentalizing approach has also

led to the development and manualization of specific mentalization-based treatments,

including MBT for BPD (Allen et al., 2008; Bateman & Fonagy, 2006). Here, we briefly

summarize the core principles, interventions and treatment strategies of MBT.

Our theoretical model implies that in order to maximize the impact on the patient’s

ability to think about thoughts and feelings in relationship contexts, especially in the early

phases of treatment, the therapist is probably most helpful when interventions (a) are simple

and easy to understand, (b) are affect focused, (c) actively engage the patient, (d) focus on the

patient’s mind rather than their behavior, (e) relate to a current event or activity – whatever is

the patient’s currently felt mental reality (in working memory), (f) make use of the therapist’s

mind as a model (by therapists disclosing their anticipated reaction in response to the event

being discussed, i.e., talking about how the therapist anticipates that he or she might react in

that situation), (g) flexibly adjust complexity and emotional intensity in response to the

intensity of the patient’s emotional arousal (i.e., withdrawing when arousal and attachment

are strongly activated).

The key task of therapy is thus to promote curiosity about the way mental states

motivate and explain the actions of self and others. Therapists achieve this through the

judicious use of the “inquisitive stance”, highlighting their own interest in the mental states

underpinning behavior, qualifying their own understanding and inferences (showing respect





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for the opaqueness in mental states), and demonstrating how such information can help the

patient to make sense of their experiences. Pseudomentalization and other fillers to replace

genuine mentalization must be explicitly identified by therapists, and the lack of practical

success associated with them clearly highlighted. In this way therapists can help their patients

to learn about how they think and feel about themselves and others, how that shapes their

responses to others, and how “errors” in understanding self and others may lead to

inappropriate actions. Put simply, it is not for the therapist to “tell” patients about how they

feel, what they think, or how they should behave, or what the underlying reasons may be for

their difficulties. Any therapy approach that moves towards claiming to “know” how patients

“are”, how they should behave and think, and “why they are the way they are”, is likely to be

harmful to patients with a vulnerable capacity to mentalize.

This principle applies to CBT as much as to psychodynamic psychotherapy. For

example, Davidson and colleagues demonstrated that high levels of therapist integrative

complexity (an indication of the number of ideas being combined in a single statement) was

associated with relatively poor outcome in CBT, while the patients’ increase in integrative

complexity marked improvement in social functioning (Davidson, Livingstone, McArthur,

Dickson, & Gumley, 2007).

Individuals with BPD may perform experimental mentalizing tasks relatively well

under low arousal (Arntz, Bernstein, Oorschot, & Schobre, 2009), but cannot explain the

states of mind they experience under high arousal. Unfortunately, psychotherapists of many

orientations often attempt to provide mentalistic understandings for issues that trigger intense

emotional reactions (challenging interpersonal situations, issues of shame, guilt, feelings of

inadequacy, etc.) at a time when the patient’s capacity for effective explicit mentalization is

practically inaccessible (Fonagy & Bateman, 2006). Particularly in severely disturbed BPD

patients, treatments that strongly rely on reflective capacities might actually become





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iatrogenic (Lemma, Target, & Fonagy, 2011; Luyten, Fonagy, Lemma, & Target, 2012).

Such patients may benefit more from a mental process or mentalizing approach, where the

focus is on distortions in processes related to the metacognitive ability to reflect on the self

and others (Fonagy, Moran, & Target, 1993; Luyten, Blatt, & Fonagy, 2013). A titrated but

more or less exclusive focus on the BPD patient’s current mental state while activating the

attachment relationship is expected to enhance the patient’s mentalizing capacities without

generating iatrogenic effects. Hence, treatment should avoid situations where patients are

expected to talk of mental states that they cannot link to subjectively felt reality. In the case

of BPD, we argue that the therapeutic aim needs to be reconfigured away from the traditional

psychodynamic pursuit of insight, to an emphasis on the recovery of balanced mentalizing:

the achievement of representational coherence and integration. Thus, with regard to dynamic

therapies, there should be (a) a de-emphasis of “deep” unconscious interpretations in favor of

conscious or near conscious content, (b) careful eschewing of descriptions of complex mental

states (e.g., conflict, ambivalence, unconscious) that are incomprehensible to a person whose

mentalizing is vulnerable, (c) avoidance of extensive discussion of past trauma, except in the

context of reflecting on current perceptions of mental states of maltreating figures and

changes in mental state from being a victim in the past versus one’s experiences now. Careful

attention to the BPD patient’s current mental state, while activating the attachment

relationship, serves to enhance the patient’s mentalizing capacities without generating the

iatrogenic effects that can arise from the activation of a disorganized attachment system.

MBT Structure and Protocol

MBT is organized around the development of an attachment relationship with the

patient, offering a careful focus on the patient’s internal mental processes as they are

experienced moment by moment and emphasizing the therapeutic alliance with the active

repair of ruptures in the patient–therapist relationship (Bateman & Fonagy, 2009).





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Importantly, the treatment is delivered according to a carefully constructed protocol, which

informs the therapist about how to manage common clinical situations using basic principles.

In sum, these are:

1. A collaborative approach to and formulation of patient problems

2. Identification of non-mentalizing processes

3. General stance

a) Interventions consistent with the patient’s mentalizing capacity

b) Monitoring of the state of affective arousal

c) Focus on maintaining therapist mentalizing

d) Openness of therapist’s mind states and explicit identification of therapist’s

feelings related to patient’s mental states

e) Alert to breaks in mentalizing.

4. “Not-knowing” stance of curiosity

5. Identification of mentalizing poles

6. Trajectory of sessions: implementation and marking interventions structured from

empathic validation to exploration, clarification, and challenge through affect

identification and affect focus to mentalizing the relationship and counter-

relationship.

1. Collaborative approach and formulation

The therapist generates a collaborative process in which both patient and therapist

become inquisitive about agreed difficulties. Problems are initially organized in a mentalizing

formulation, which is jointly agreed and reviewed every three months. Overall, the

collaborative approach is embedded in the therapist’s general stance and attitude.





December 30, 2014.

2. Identification of non-mentalizing process

Clinicians carefully monitor for non-mentalizing processes. This is indicated for

example by over-generalization, fixed beliefs of self and other, motives understood in terms

of behaviors rather than mental states. Some non-mentalizing states are indicated by the

therapist’s behavior. Therapists who lose concentration or only grunt as the patient talks are

often affected by pretend mode functioning in the patient; therapists suggest how to solve

problems or tell the patient what to do without exploration are likely to be involved in

teleological processes; the confused therapist who nods wisely is often struggling with

understanding psychic equivalence. However, it should be noted that the three primary non-

mentalizing modes are not mutually exclusive and are more likely to interweave than to

manifest in pure form.

3. General stance

There are certain general principles for the therapist to follow in the clinical practice

of MBT (Bateman, 2012).

a) Any intervention needs to take into account the patient’s mentalizing ability. If

their state of mind is held in psychic equivalence, complex interpretation or

cognitive appraisal of the validity of the belief will be outside their

comprehension. Such interventions need a higher level of mentalizing if they are

to be effective. Fundamentally, the patient has to be able to think about his/her

current state and appraise it without “living” it before such interventions are

useful.

b) The therapist takes into account the patient’s current affective state. If the patient

is aroused, mentalizing will be compromised; the therapist needs to deal with the

emotional dysregulation first. Once the patient begins to mentalize, the therapist

can increase focus on affect.





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c) The therapist ensures that he/she maintains his/her own mentalizing. This is a

priority in MBT. If the therapist’s mentalizing is lost, retrieving it takes

precedence over all other processes; if necessary, the therapist temporarily stops

the session to facilitate this. Openly retrieving one’s own mentalizing is a useful

model for the patient: “I am sorry I lost my ability to concentrate there and

became too reactive when I said that. Let me go back…”

d) The openness of the therapist’s mind states in relation to the patient’s mind states

is central to MBT. The therapist will talk about what is in his/her mind in relation

to the patient’s mind. In this regard there is a certain level of self-disclosure, but

this is carefully “marked”. Marking is explicitly identifying whether what is said

is the therapist’s state of mind, his/her subjective experience, or the therapist’s

representation of the patient’s state of mind. For example, the therapist’s

statement “I am confused” is about the therapist’s state, but “It comes across to

me that you are confused” is about the patient.

e) The therapist is sensitive to breaks in mentalizing as evidenced by the dialogue,

and is alert to changes in the patient’s emotional arousal. This ensures that the

patient focuses on actual mental processing as it happens and begins to recognize

that emotions disrupt thoughts and interpersonal process.

A patient was talking about her children, who had been taken into care through child

protection procedures, and her determination to have them back. She became angry about

how she had been treated, then abruptly said that what was really a problem for her was that

the gearbox had gone on her car and the drive shaft had broken. The therapist captured this

sudden change in topic by saying “What happened there? How come you suddenly shifted to

your broken car away from the children? What happened in your mind?”





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The therapist also seeks to see whether he/she contributed to any break in mentalizing

that occurs in the therapy. This will indicate how sensitive the patient is to aspects of

interpersonal interaction. For example, when the therapist said “Calm down” to a patient in a

concerned manner, the patient reacted strongly by saying “Don’t tell me what to do. I am not

taking orders from you”. The therapist’s remark had triggered a sensitive area, which could

be recognized and explored to stimulate the patient’s capacities to monitor how he/she

processes his/her thoughts and feelings and what impairs these capacities.

4. Not-knowing stance

The not-knowing stance requires the therapist to work authentically from the

perspective of equality and collaboration – the therapist can never know what is really going

on in others’ mind states. The therapist has to accept the validity of the patient’s experience

even if he/she does not understand it. The therapist does not have to understand the patient or

to make sense of what seems incomprehensible. If the therapist does not know what the

patient is talking about, the therapist does not try to piece it together but says: “You know, I

am having a real problem here, I can’t follow this, I can’t put it together, can we try again?”

The aim of the not-knowing stance is to rekindle mentalizing in the session, to reflect

on non-reflection as manifested in non-mentalizing. It is a key therapeutic attitude to enhance

curiosity about mental process and experience. Curiosity is modelled by the therapist through

reflecting on his/her own mind states without judgment and with empathic acceptance of

experience.

5. Identification of Mentalizing poles

The therapist becomes attuned to indicators of non-mentalizing in the dialogue such

as overuse of absolutes, simplistic over-determined explanations, and mental rigidity, which

arises when the patient becomes stuck at one of the poles of mentalizing; the therapist tries to





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rebalance this. For example, if the patient is highly other-externally focused, watching the

therapist’s movements carefully, the therapist directs the dialogue toward an internal state to

see whether this instils more reflection.

A patient stated that the therapist was not to turn around to look at him as they

walked down the corridor to the consulting room. The therapist asked what this backward

glance did to the patient – an intervention to focus the patient on “self-internal” to balance

his “other-external” focus. The patient kept the focus on the therapist and so the therapist

accepted the patient’s “other-external” focus by saying he turned around simply as a social

gesture and that he was not aware of any wish to offend. Having done this, the therapist

again tried to rebalance the focus by asking the patient to describe what he had experienced

from the backward glance.

The same maneuver can be used if a person is excessively self-focused. The therapist

intervenes to pull them out and get them to consider the “other” in some way, to balance their

fixed focus on self.

The self–other dimension can be focused upon in two ways. The first is by getting the

patient to shift internally toward thinking about the other – for example, if they are blaming

themselves for a relationship problem, they may be supported in focusing on the role of the

partner. The second way is by harnessing the intersubjective, interpersonal experience

between the patient and therapist. MBT involves both ways. So the therapist could say to a

patient, on the one hand, “How are you so sure that you are useless and that the relationship

problem is all you? What about your boyfriend’s role in this?” or, on the other hand, “I have

never seen you like that. We seem to have a big difference here”.

The same principle applies if a patient is excessively cognitive. The therapist balances

this by harnessing the use of affective experience. This move to the affective pole can be

difficult without becoming formulaic, for example, by continually asking someone how they





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feel. This can be irritating for the patient, who may not know how they feel, and is often an

unproductive intervention in terms of stimulating further mentalizing. For the therapist, the

important factor is the quality of mentalizing – that is, whether it has become fixed and rigid

rather than whether the mental processing is cognitive or affective. MBT recommends that

the therapist increases interpersonal affectivity when the patient is fixed in a rigid cognitive

rational process, or increases cognitive processing when the patient is trapped in affective

dysregulation. To move from the cognitive pole, the therapist uses relational interventions in

the dialogue (e.g., asking how the patient is feeling about someone); to move away from the

affective pole, the therapist reduces the relational component and becomes more practical.

For example a patient was talking about how she wanted her baby back. She stated ‘no one

else is having my baby’. ‘They are not entitled to my baby. She is mine.’ She had worked out

that if she behaved herself in a particular way when she was with the social workers they

would think that she was now emotionally controlled and release her baby from child

protection. She did not want her child fostered so she had worked out a strategy for not telling

people about problems. This rationale was presented in the session. The therapist considered

this to be a cognitively determined level of mentalizing of both self and other so he increased

the relational and affective component of the dialogue. He said that he could see that she had

worked out what to do to meet her goal of not letting someone else have her baby. But he had

always had a sense that it was her love for her baby that meant she wanted her back rather

than the entitlement. This was an initial intervention to increase the affective component of

the dialogue and to place the therapist’s perspective as a relational aspect of the dialogue.

From here the discussion moved to the relationship the patient had with her baby and if she

could meet the baby’s emotional needs. The aim of these interventions is to make a

mentalizing process more flexible, more responsive to context, and increasingly implicit.





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6. Trajectory of sessions

Empathy and support. MBT not only has an overall structure to the treatment

programme (Bateman & Fonagy, 2006), but also identifies a trajectory for each session. In

each session there is a recommended stepwise move from a supportive position toward a

more relational, subjective, experiential process. MBT requires the therapist to start from an

empathic and supportive position before moving toward a more relational focus. The

therapist seeks to demonstrate an empathic understanding by using validation as the starting

point, finding out the subjective truth of the patient’s experience, and demonstrating that

he/she has understood it from the patient’s perspective. Only then can the therapist “sit

alongside the patient” so that they both look at subjective experience from a shared vantage

point.

A patient asked, “Do you know what I have gone and done?” The patient stated that

what she had done was utterly crazy. “I’ve got myself a job.” From the not-knowing stance,

the therapist asked what was so crazy about it. The patient explained why it was crazy from

her perspective. She had thought it was time she went to work and so got a part-time job, but

explained that now she was working, paradoxically, she was earning less than when she had

received unemployment benefit. So the therapist said “That is crazy – working and having

less money and increased costs!” In this sense the therapist is empathic about her experience

of being crazy. Taking an initial attitude that the decision was not crazy would have

undermined the alliance and potentially left the patient feeling misunderstood. The

complexity of the balance between the “craziness” and “about time I went to work” can be

considered and explored later. The patient talked about getting less money, having to get out

of bed, having to interact with people, and why the hell was she doing this? At this point the

therapist was empathic, saying “That’s a great question. Why do that?” It is from there that





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the therapist and patient together work out what made her take the decision and what it had

given her in terms of self-esteem.

Exploration and clarification. As soon as the therapist senses that he/she and the

patient have a shared affective platform, exploration and elaboration takes place with the

clarification of mental states. In the example above, the therapist helps the patient elaborate

and clarify the processes that she went through to make her decision, and how she came to a

final conclusion that she wanted employment despite it being “crazy”. In addition, the

therapist brings in some of his/her own thoughts about it. Clarification requires a

reconstruction of events, but with an emphasis on the changing mental states, a tracing of

process over time, and a recognition that decisions may be capricious and yet also of value.

Challenge. Challenge as an intervention has certain defined characteristics: it is

nearly always outside the normal therapy dialogue, out of line with the current dialogue, and

comes as a surprise to the patient. The aim is for the patient to be suddenly derailed in their

non-mentalizing process. If the intervention is successful, the therapist “stops and stands” the

moment to prevent the patient continuing in the same mode. Once a stop and stand challenge

has been effective in halting non-mentalizing, it is important to rewind to the point at which

either the patient or therapist was mentalizing.

A female patient was engaged in a diatribe about the prison service and its ill-

treatment of prisoners. She was highly aroused, shouting, ranting, and “reliving” her anger

and rage. Any interruption by the therapist resulted in a dismissive comment. The therapist

looked out of the window, wondering how to intervene and thinking that a challenge was

necessary. As he looked out of the window, the patient said, “Don’t look out the window, you

listen to me”. So the therapist retorted that he could look and listen at the same time, stating

that he could multi-task. Before the patient could respond, he said, “Do you know why I can

multi-task? Because I am a man.” At this point the patient stopped, not knowing whether to





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laugh or react contemptuously. The therapist said that as a man he could only multi-task for

a short time, so exhorted her to rest for a moment so that they could both collect their

thoughts. This was a challenge: it was unexpected, and it stopped the ranting. The therapist

was able to say that he thought it was better to sit back for a few minutes and rewind the

session to start reflecting about what had happened that had led her to be sent to prison.

Affect focus. Once therapist and patient are able to maintain a mentalizing

interaction, MBT suggests increasing focus on affect and the interpersonal domain. The

purpose of this is to recreate the core sensitivity of BPD patients in the session itself. People

with BPD are highly sensitive to interpersonal process; arousal in the interpersonal domain

triggers emotional dysregulation, which in turn disrupts mental processing further. MBT for

BPD focuses on this area of sensitivity to generate more robust mentalizing around

interpersonal processing.

Affect focus is not simply labelling feelings – it is a way of increasing affective

experience within the interpersonal relationship in the session by identifying implicit

mentalizing and making it more explicit when the therapist and patient share some implicit

process. It requires the therapist to recognize that both he/she and the patient are making

unquestioned, jointly held, unspoken, assumptions. So the therapist names the experience as

something that is shared between them.

A patient was anxious in a session and managed his arousal by turning away from the

therapist, falling silent and then saying “Yeah, yeah, I don’t know”. Implicit in this

interactive process was the patient’s assumption that the therapist wanted him to talk more;

there was some truth in this, for the therapist probed further at such times. But it was also

apparent that the patient struggled with fears of becoming emotionally dysregulated to the

extent of having to leave the session. The therapist was in a similar position with his

assumption that the patient wanted to say more and his wariness that probing further could





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increase the patient’s anxiety. MBT suggests that the therapist identifies the shared dilemma,

making the implicit anxiety more explicit. In this example, the therapist said “We are both

uncertain at the moment. With me, I am concerned that if I probe more it will make things

worse for you and yet this is an area that we have to explore more. It looks to me like you are

saying ‘don’t go further because it might not be safe to continue’. Where are you in this?”

Having made this shared dilemma explicit, the therapist develops the mentalizing

process around this interpersonal affectively charged area. To some extent this is a rehearsal

in vivo of an affectively salient interpersonal interaction that may derail the patient in their

close relationships. Accurate identification of the current affectively salient focus allows the

therapist to segue to mentalizing the relationship without clumsily disrupting the

interpersonal process.

Mentalizing the relationship. The aim of mentalizing the relationship is to increase

the affective interpersonal experience with the patient whilst maintaining mentalizing. If an

attempt to mentalize the relationship triggers non-mentalizing, the process is abandoned and

the therapist returns to empathy and supportive work before trying to move down the

relational trajectory again. If mentalizing continues as the focus on the relationship

progresses, MBT suggests a number of steps for the therapist to take.

If the patient says something within the patient–therapist relationship that is of

significance in the patient’s external relationships, the first task for the therapist is to validate

the patient’s experience. Next, the therapist has to explore this sensitive area to get to an

alternative perspective, or at least, a more complex understanding of what has happened.

A patient told her therapist that he was too modest. To validate this experience, the

therapist asked the patient what he does that is “too” modest. Importantly, he did not

question it as a distortion; it is a valid experience contributed to by the therapist’s attitude.

After the patient explained her reasons for believing that the therapist was too modest, and





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identifying a recent example, the therapist’s task is to identify what it is like for the patient to

be working with a therapist who is too modest – what does it matter that she has a therapist

who she sees as too modest? What actually had happened was that the patient felt that if the

therapist could not be proud of his achievements, it reduced her own achievements in life to

futile meaningless events, because she saw them as being minimal compared to those of the

therapist. She experienced this in psychic equivalence, so her experience of her achievements

as useless meant that she as a human being was useless.

Mentalizing the relationship is an attempt within the relationship to generate

meaningful complexity about what has happened by engaging in a slowly unfolding relational

process. At all times the therapist monitors the patient’s reaction to the alternative

perspective.

MBT adds caution in mentalizing the relationship. Side effects stimulated by the

therapist are common: for example, if the patient’s experience is seen by the therapist as a

distortion and the patient is alienated, or if the process becomes a jointly elaborated pretend

mode in which both patient and therapist believe that they are working at depth when in fact

they are engaged in clever cognitive work that is out of contact with affective reality.

Mentalizing the counter-relationship. Mentalizing the counter-relationship, by

definition, links to the therapist’s self-awareness and often relies on the affective components

of mentalizing. Some therapists tend to default to a state of self-reference whereby they

consider most of what they experience in therapy as relevant to the patient. This default mode

needs to be resisted; therapists need to be mindful that their mental states might unduly color

their understanding of the patient’s mental states and that therapists tend to equate them

without adequate foundation. The therapist has to “quarantine” his/her feelings. How the

therapist does so informs the MBT technical approach to countertransference – defined as

those experiences, both affective and cognitive, that the therapist has in sessions which he/she





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thinks might further develop an understanding of mental processes. Feelings in the therapist

are not considered initially as a result of projective processes and the therapist must identify

experiences clearly as his/her own. That is, they are “marked”, and interventions using the

counter-relationship are stated as the therapist’s experience.

The simplest way to release countertransference experience from quarantine without

equating the therapist’s feeling with that of the patient is for the therapist to state “I” at the

beginning of an intervention. Intriguingly, this seems to be difficult for therapists, who

understandably worry about violating therapeutic boundaries. Yet MBT does not suggest that

therapists start to express their personal problems or talk about any feeling they might have in

a session, whether relevant to the process or not. Rather, the therapist’s current experience of

the process of therapy with the patient is to be shared openly, to ensure that the complexity of

the interactional process can be considered. Patients need to be aware that their own mental

processes have an effect on others’ mental states and that these, in turn, will influence the

interaction.

A patient with antisocial personality disorder sat in sessions leaning forward, pointing

his finger at the therapist as he talked, and often using threatening language. Naturally this

unnerved the therapist. The therapist was aware that the more unnerved he became the less

likely it was for him to be able to maintain his mentalizing. At an appropriate moment in the

discussion the therapist presented his current feelings in the therapy. ‘Now you mention the

way you intimidate people perhaps I can bring something up here related to that. I don’t want

to divert our discussion but many times in this session I have felt intimidated even if you

don’t mean to intimidate me. It is a problem because I find I can then not easily concentrate

on what you are talking about.’ At this point the patient interrupted to say that it was the

therapist’s problem if he felt intimidated. So the therapist agreed and said that indeed it was

his problem but because of the effect it had on him it then became a problem for treatment.





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This allowed the patient and therapist to consider intimidation in interpersonal interactions

and it became apparent that the patient was unaware of the effect he was having on others by

his attitude and discourse.

Common countertransference experiences associated with particular modes of

psychological functioning include boredom with pretend mode, and anxiety to do something

with psychic equivalence. Therapists need to become comfortable with managing these states

of mind and be able to express them constructively in the service of extending the patient–

therapist collaboration.

In all circumstances the therapist, once alerted by a change in his/her own feelings or

behavior, should focus more carefully on his/her feeling and identify it openly – a move from

implicit functioning to explicit process allowing a shared scrutiny.

It is highly likely that our formulations concerning the role of mentalizing in BPD

also have implications for other evidence-based treatments of this condition. In fact, we

believe that these formulations clarify the role of common factors in these treatments, and

suggest the need to develop more comprehensive and integrative treatments that focus on

restoring the capacity for social learning in patients with BPD and allied conditions.

Conclusion

This paper emphasizes the simultaneous consideration of disruptions in three closely

linked domains in individuals with BPD: (a) in attachment relationships, (b) in different

polarities of mentalizing, and (c) in the quality of epistemic vigilance and trust. Such a focus

not only provides a comprehensive understanding of patients with BPD, rendering seemingly

paradoxical features of patients with BPD more comprehensible. In so doing, this approach

also provides a clear therapeutic focus, enabling the therapist to monitor the therapeutic





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process in terms of (impending) mentalizing impairments and epistemic mistrust as a result of

the activation of the attachment system. We believe that the effectiveness of the mentalizing

approach in helping patients with BPD might be particularly explained by the fact that it

enables the therapist to maintain and foster a mentalizing stance, even – and perhaps

particularly – under high arousal conditions, so typical of work with these patients. As a

result, MBT may lead to a relaxation of epistemic hypervigilance in these patients, opening

them up for what fundamentally characterizes human beings: an openness to learn from

others about oneself, others, and oneself in relation to others.

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translation: mentalizing as treatment target in...

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